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Beware the scar

Laparoscopic hysterectomy for 7-week cesarean delivery scar implantation pregnancy
Published:October 30, 2014DOI:https://doi.org/10.1016/j.ajog.2014.10.1096

      Case notes

      A 36-year-old G4P2012 at 6 weeks by last menstrual period presented to the emergency department with abdominal pain and vaginal bleeding. On examination, she had normal vital signs with mild suprapubic tenderness without rebound or guarding. Her medical history was notable for 2 uncomplicated cesarean deliveries.
      Ultrasound imaging showed implantation of a 7-week gestation within the endometrium overlying the prior cesarean delivery scar with thin adjacent myometrium. The serum human chorionic gonadotropin (hCG) was 155,009 mIU/mL. Due to the rare nature of cesarean delivery scar implantation pregnancies, there are no standardized guidelines for management. After extensive counseling regarding surgical management vs medical management with intraamniotic KCl injection and multidose methotrexate, the patient opted for medical management.
      • Ash A.
      • Smith A.
      • Maxwell D.
      Caesarean scar pregnancy.
      • Litwicka K.
      • Greco E.
      Cesarean scar pregnancy: a review of management options.
      She was admitted to the gynecology service after undergoing intraamniotic KCl 6-mEq injection under ultrasound guidance with confirmed cessation of the fetal heartbeat. The patient then received 4 doses of methotrexate (1 mg/kg intramuscularly) with a 5-mg leucovorin ‘rescue’ on alternating days. Following an initial decline in serial hCGs, the hCG plateaued and never fell below 131,000 mIU/mL. Dilation and curettage was not offered after reviewing the imaging given concern for perforation in the setting of minimal myometrium separating the implantation and the bladder (Figure 1).
      Figure thumbnail gr1
      Figure 1Ultrasound showing implantation of 7-week gestation in cesarean delivery scar
      Berhie. Beware the scar. Am J Obstet Gynecol 2015.
      The patient was offered excision of the cesarean delivery scar implantation with wedge resection vs total laparoscopic hysterectomy (TLH). This was an undesired pregnancy and she did not desire future fertility, thus she opted for definitive surgical management with a TLH. She underwent an uncomplicated TLH and was discharged on postoperative day 1 (Figure 2).
      Figure thumbnail gr2
      Figure 2Uterus with pregnancy located in the cesarean delivery scar after TLH
      TLH, total laparoscopic hysterectomy.
      Berhie. Beware the scar. Am J Obstet Gynecol 2015.

      Comment

      In 2012, the cesarean delivery rate in the United States was 32.8% while the rate in other developed countries was 21.1%.
      • Betrán A.P.
      • Merialdi M.
      • Lauer J.A.
      • et al.
      Rates of cesarean section: analysis of global, regional and national estimates.

      Centers for Disease Control and Prevention. Births–method of delivery. Available at: http://www.cdc.gov/nchs/fastats/delivery.htm. Accessed Sept. 5, 2014.

      The only risk factor for a cesarean delivery scar implantation is a history of cesarean delivery. While these pregnancies are still rare, occurring in about 1 in 2000 pregnancies of women with a prior cesarean delivery and account for 6% of ectopic pregnancies, the increasing incidence of cesarean deliveries in the United States may lead to a higher incidence of cesarean delivery scar implantation in the future.
      • Rotas M.A.
      • Haberman S.
      • Levgur M.
      Cesarean scar ectopic pregnancies: etiology, diagnosis, and management.
      Management of advanced pregnancies in the setting of a prior hysterotomy poses unique medical and surgical challenges, and data remain limited in guiding treatment.

      References

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      1. Centers for Disease Control and Prevention. Births–method of delivery. Available at: http://www.cdc.gov/nchs/fastats/delivery.htm. Accessed Sept. 5, 2014.

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